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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336402223
Report Date: 01/09/2020
Date Signed: 09/30/2021 04:12:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2019 and conducted by Evaluator David Cuevas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191108085934
FACILITY NAME:AMY'S HOUSEFACILITY NUMBER:
336402223
ADMINISTRATOR:AILEEN ADAMSFACILITY TYPE:
735
ADDRESS:3731 CALIFORNIA AVETELEPHONE:
(951) 372-0554
CITY:NORCOSTATE: CAZIP CODE:
91760
CAPACITY:4CENSUS: 4DATE:
01/09/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Aileene AdamsTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff physically restrained resident
Staff hit resident
INVESTIGATION FINDINGS:
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Please Note: The following is an amended report for facility visit that occurred on 01/09/20.

Licensing Program Analyst (LPA), David Cuevas conducted an unannounced visit to the facility above to deliver findings LPA met with Administrator, Aileene Adams who was informed of the purpose of visit.

During the investigation, LPA Cuevas conducted a facility file review, resident record review, and interviews with staff, witnesses, and resident.
Regarding Allegation: #1 Staff physically restrained resident.

Interviews with witnesses confirmed R1 was observed by three witnesses to have been physically restrained by Staff #1 (S1) while being picked up from the Day Program. The incident occurred on November 7, 2019 at approximately 2:08 pm; According to statements provided S1 was picking up R1 from the day program at the end of the day.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20191108085934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AMY'S HOUSE
FACILITY NUMBER: 336402223
VISIT DATE: 01/09/2020
NARRATIVE
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Per witnesses, S1 grabbed R1 by the cheeks and pushed R1 into the vehicle and then physically restrained R1 by pushing R1 back into the vehicle by the neck and shoved R1 by the face. Furthermore, in a personal statement provided by S1, it states that S1 could not apply CPI alone and could have unintentionally hurt resident trying to apply CPI. Staff hitting R1 could have been done unintentionally due to the overwhelming situation; however, there is enough evidence to SUBSTANTIATE allegation.

Based on the statements the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Regarding allegation #2 Staff hit resident

Interviews revealed S1 slapped R1 in the face when R1 attempted to leave the vehicle. Furthermore, in a personal statement provided by S1, it states that S1 could not apply CPI alone and could have unintentionally hurt resident trying to apply CPI. Staff hitting R1 could have been done unintentionally due to the overwhelming situation; however, there is enough evidence to SUBSTANTIATE allegation.

Based on statements, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

California Code of Regulations Title 22 are being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator, Aileene Adams were a copy of this report, LIC 9099 D, and appeal rights were discussed and provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20191108085934
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AMY'S HOUSE
FACILITY NUMBER: 336402223
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/14/2021
Section Cited
CCR
80072(a)(3)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Licensee will ensure that staff will refrain from restraining and hitting clients in care, a statement of understanding must be provided by Licensee for section cited. In addition, all facility staff members must participate in training in regard to properly addressing client behaviors and resident rights. Proof of correction must be submitted by provided due date.
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This requirement was not being met as evidenced by: Based on interviews, S1 physically restrained R1 by grabbing R1 back of the neck and shoving R1 by the face. This posed an immediate health and safety risk to resident in care.
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Type A
10/14/2021
Section Cited
CCR
80065(1)
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(l) Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice.
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Licensee will provide training with all staff members to discuss personal rights of residents and ensure they understand that pysical abuse and verbal abuse are not allowed, by due date.
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This requirement was not being met as evidenced by: Based on interviews, S1 slapped R1 when R1 attempted to leave the vehicle.This posed an immediate health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3